The emergency department (ED) is a vital location for providing health care services, assisting nearly 150 million individuals annually in the US.1 It is also an important setting to consider when analyzing trends in antibiotic use with emergency medicine (EM) providers, who are responsible for approximately 12 million outpatient antibiotic prescriptions annually.1,2 Unfortunately, nearly one-third of these prescriptions may be inappropriate or unnecessary, prompting the implementation of antimicrobial stewardship interventions such as ED culture followup.3 The inappropriate use of antimicrobials contributes to antimicrobial resistance, adverse drug events, and Clostridioides difficile infections, making optimization of antimicrobial use a patient safety priority.4
The general workflow of an ED culture follow-up program is prompted by a review of microbiological testing (eg, blood cultures, urine cultures, sexually transmitted infection testing, etc) updates that result after a patient is discharged from an ED. Optimal situations for intervention include, but are not limited to, the following:
- An organism that likely represents a pathogen in patients with signs and symptoms consistent with infection was identified but not treated by the time of ED discharge.
- An organism that likely represents a pathogen in patients with signs and symptoms consistent with infection was identified but empirically treated with an ineffective antimicrobial after ED discharge.
- An organism that warrants further infectious disease workup and a return to the ED was identified.
Once these situations are identified, an alternative treatment plan is created, and the patient is instructed to pick up a new antimicrobial prescription or seek additional medical attention. There may also be opportunities to integrate antimicrobial stewardship audit and feedback processes to educate prescribing clinicians, representing a core practice for improving antimicrobial use supported by the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, CDC, and Joint Commission.5-8
Historically, many ED culture follow-up programs relied heavily on physicians, advanced practice providers, and nurses. Nurses often play critical roles in these programs as liaisons between microbiology laboratory personnel, prescribing clinicians, and patients.9-11 Additionally, nurse-led postdischarge programs have demonstrated significant reductions in ED revisits.9 With the expansion of emergency pharmacy services and quality improvement initiatives nationwide, models that integrate pharmacists have become increasingly common.10-18 Additionally, the American Society of Health-System Pharmacists advocates for pharmacist integration in ED culture follow-up programs due to downstream decreases in time to positive culture review and notification of a patient or primary care provider, reductions in revisits and readmissions, and improved appropriateness in antimicrobial prescribing.19
Pharmacist roles and responsibilities may differ across ED culture follow-up programs, but multidisciplinary collaboration and independent practice are common strategies. Although some programs place full responsibility on pharmacists via collaborative practice agreements or other institutional protocols to optimize antimicrobial use without compromising clinical outcomes, many rely on multidisciplinary conversations and consultation.10-13 Pharmacist integration is associated with increased guideline-concordant antimicrobial prescribing and decreased antimicrobial prescribing for inappropriate indications, such as asymptomatic bacteriuria.10 One site demonstrated these trends after updating their program so that nurses identified urine cultures for pharmacist review; pharmacists made recommendations to EM providers to optimize antimicrobial selection, dosing, and duration; and EM providers finalized treatment plans.10 Similar benefits in antimicrobial use have been described among community EDs with collaborations between pharmacists and advanced practice providers.14 Pharmacists can also support ED culture follow-up programs by contacting patients and counseling them on their updated results and treatment plans, which can help decrease the workload of EM providers and unplanned ED readmissions.15 Additionally, results from several studies have demonstrated that pharmacist-facilitated culture review correlates with quicker action and a greater intervention volume than nurse-driven protocols.16,17
